Anesthesia for Head and Neck Cancer
3/27/2015 Financial Disclosures • None Anesthesia for Head and Neck Cancer Laura L. Ardizzone DNP, CRNA, DCC Director Nurse Anesthesia Services, MSKCC Adjunct Assistant Professor of Nursing Fairfield University School of Nursing [email protected]/www.mskcc.org Objectives At the conclusion of this presentation, the participant should be able to : 1. Examine the etiology of major head and neck cancer 2. Describe the peri-operative management of patients undergoing surgery related to head and neck cancer 2012 14.1 million new cases 8.2 million cancer deaths 32.6 million survivors (within 5 years of diagnosis) WHO/International Agency for Research on Cancer 2012 Worldwide incidence and mortality by cancer type MALE Incidence Mortality US Statistics – New cases in 2015 by state FEMALE 1. 2. 3. 4. 5. Lung Breast Colorectal Prostate Stomach American Cancer Society, 2015 1 3/27/2015 2015 New Cancer Incidences by Gender As of 1/2014 ~14.5 million Americans survivors 1620 Americans die each day Mortality usually results from recurrence or metastases Head and Neck Cancer • Worldwide 644k incidence and 350 k deaths • 50,000 Americans are diagnosed with a head or neck cancer (not including skin cancers that occur in the head or neck) – ~ 5 percent of all cancers in the US – Majority are squamous cell carcinoma • Survival rates have improved – aggressive gg treatment – early detection – declining rates of tobacco and ETOH abuse • The role of HPV – The % of oropharyngeal cancers caused by human papillomavirus (HPV) has increased – 80% of oropharyngeal cancers are now caused by HPV (industrialized countries) HPV related H & N cancer – what the epidemiologic evidence shows us ? HPV related H/N Cancer HPV unrelated H/N cancer Incidence trend Increasing Decreasing/stable Anatomic Location Tonsil and base of tongue All H /N sites Median age @ diagnosis 54 60 Socioeconomic status Higher Lower Primary risk factors Sexual Exposure to oral HPV Tobacco & Etoh exposure Survival Better Worse 82 57 3yr oropharyngeal % Warning – graphics photos ahead • More likely to have an oropharyngeal primary tumor, diagnosed at a late stage, and better survival than those with HPV-unrelated HNSC • Race association incidence vs mortality Considerations General Considerations for Head and Neck surgery • Airway Management – Anatomy (c-spine, +/ROM, large tongue) – stridor or hoarseness – hx neck surgery, trauma, difficult intubation – infections (epiglottitis, abscess) – head/neck cancer radiation therapy • low threshold for fiberoptic • backup plan • sharing of airway with surgeon • nasal intubation 2 3/27/2015 General Considerations General considerations • Preoperative evaluation – elderly comorbidities – hx of smoking, EtOH • OR 3.49 = cigars • OR 3.71 = Pipes – Hx CAD, HTN, CRI, COPD – Prior anesthesia hx – preop testing imaging studies, PFTs, cardiac and hepatic function • Monitoring and access – – – – – – – – ECG BP noninvasive vs. arterial pulse Ox temp end tidal CO2 RLN nerve monitoring current practice large bore IV, good access positioning arms tucked, all access prior, sticky pulse ox, nerve stimulator (where?) Wyss, A. et. Al Am. J. Epidemiol. (2013) 178 (5): 679-690. doi: 10.1093/aje/kwt029 General Considerations Anesthesia for Thyroidectomy • Anesthetic Management • Preoperative Assessment – – – – – – – – Adequate intra op/postop analgesia, highly reflexogenic areas controlled hypotension – dec SBP< 100mmHg, MAP 60-70 Pt immobility muscle relaxation ? Smooth emergence Opioid based technique antiemetic prophylaxis OGT prior to emergence to empty stomach +/General with ETT vs. flexible ETT Preoperative Assessment: Thyroidectomy – Airway – Cardiac Hx – Pre oxygenate inc BMRinc VO2desat quickly – Higher incidence of myasthenia gravis and skeletal muscle weakness inc sensitivity to muscle relaxants – Large IV – Positionhead extended, arms tucked – Hyperthyroidism: excess thyroid hormone(T3 + T4) – s/sx: fatigue, sweating, heat intolerance, ↑HR, ↑BP, ↑Temp, weight gain/loss, goiter, exophthalmos – tx is medical therapy or subtotal thyroidectomy – euthyroid prior to surgery – pt should have normal thyroid function test prior to surgery and HR < 85 – Antithyroid meds and B-blockers continued through morning of surgery Intraoperative : Thyroidectomy – Protect eyes – Cardiac function monitored – Temp – Head of bed can be elevatedaids venous drainage g – +/- Reinforced ETT – Avoid drugs that stimulate sympathetic nervous system – Hyperthyroid pts can be chronically hypovolemic and vasodilated 3 3/27/2015 Intraoperative : Thyroidectomy • Maintain adequate depth of anesthesia – Remember DL is stimulant – B-blockers are your fi d friend • Not particularly painful post-op Thyroid Storm – Can occur intraop, most common 6-24 hour postop – Mimic MH intraop – Hyperpyrexia, tachycardia, altered consciousness hypotension consciousness, – Tx: hydration, cooling, esmolol infusion, propylthiouracil, sodium iodide, cortisol Anesthesia for Parathyroidectomy – “pearls” – Primary hyperparathyroidism may be associated with MEN (multiple endocrine neoplasia) syndrome pheo unrecognized fatal – Pts with osteoporosis may be predisposed to vertebral compression during laryngoscopy and bone fractures Emergence/ Postoperative :Thyroidectomy – Complete reversalintact reflexes – Recurrent Laryngeal Nerve Damage • unilateral=hoarseness • bilateral=aphonia and stridor – Hematoma formation – Hypoparathyroidismunintentional removal of parathyroid glands. (Chvostek’s and Trousseau’s) – Awake vs Deep Anesthesia for Parathyroidectomy Hyperparathyroidism: Pre -op assessment – primary causes: adenoma, carcinoma, hyperplasia of gland – secondary causes: adaptive response to hypocalcemia caused byy diseases – most clinical manifestations are secondary to hypercalcemia • HTN, ventric dysrhythmias, ECG changes, ileus, N/V, muscle weakness, mental status changes, renal stones, impaired urine concentrating, depression, anorexia, abd and bone pain Anesthesia for Parathyroidectomy • Cardiac: HTN, ↓PR↓QT intervals, hypovolemia (hypercalcemia) – Normalize Ca++ level or at least dec • volume and diuresis inc renal excretion of Ca++ • Ca++ Channel blockers reduce afterload and vasodilate coronary system=hypotension • Response to NMB may be inc sec to increased Ca++/ muscle weakness 4 3/27/2015 Intraoperative : Parathyroidectomy –Avoid hypoventilation acidosis increases ionized Ca++ –Similar to thyroidectomy –Serial lab values Anesthetic Considerations for Tracheostomy Postoperative : Parathyroidectomy • Similar to thyroid in regards to airway, RLN damage, hematoma, stridor • Hypoparathyroidism – deficit of parathyroid hormone after parathyroidectomy – manifestations are result of hypocalcemia (cardiovascular, musculoskeletal, neurologic) Intraoperative Considerations :Tracheostomy • Pre-op Assessment – population usually includes: chronically ventilated pts, pts having other procedure where trach is required, pts with upper airway obstruction (emergency) – evaluate p pt ventilation settings g – airway, coexisting dx – cardiac hx – neuro assessment may be sedated – In OR or Bedside +/- anesthesia – For intubated pts GETA – Airway compromised pts local – Inc mucosal swelling inc tissue fragility • risk of tracheal mucosal separation and false passage during trach – Communicate with surgeon when using cautery in the airway – 100% O2 required before insertion of trach Intraoperative Considerations :Tracheostomy Postoperative Considerations : Tracheostomy • Trachea opened above cuff, ETT retracted slowly with visualization of surgeon (communication), do not remove all the way until trach in place and +ETCO2 confirmation • Pneumothorax • False l passage – Transport to ICU with meds, equipment – Trach tube displacement, ETT and extra trach tube with stylet (obturator) available – Watch for bleeding – recognize, no CO2, inc PIP, absent breath sounds, rigid bronchoscope and extra ETT available 5 3/27/2015 Anesthesia for Neck Dissection • Radical, modified, or functional • Usually performed with resection of primary lesion (thyroid, parathyroid, tongue, pharynx, larynx, etc.) Intraoperative considerations: neck dissection – Moderate decrease in BP, avoid adrenergic responses – Muscle relaxant +/– Humidify gases reduce mucous plugging – VAE occurs rarely l – Manipulation of carotid sinusbradycardia, ↓BP Postoperative Considerations: neck dissection – HTN, ↑HR 2° to carotid sinus denervation – Facial nerve injury – RLN damage – Diaphragmatic paralysis – Pneumothorax – Agitation Preoperative considerations: neck dissection – Airway decreased mobility 2° to radiation • backup plan • surgeon available – Resp COPD, CO2 retention, PFTs – Cardiac: HTN, carotid artery stenosis Special focus : Right side neck dissection • Right Radical Neck dissection • may cause prolonged QT interval which may progress to ventricular arrhythmias h th i and d cardiac arrest (due to interruption of cervical sympathetic outflow to heart via right stellate ganglion Anesthesia for Laryngectomy • Total Laryngectomy – removal of vallecula to first or second tracheal rings – trachea brought out to skin as end tracheostomy – Stoma - no ETT or trach tube required • Supraglottic – resection of larnyx from ventricle to base of tongue, leave true cords – temp trach required • Hemilaryngectomy – removal of a unilateral true and false cord, keep epiglottis and opposite vocal cord – trach required 6 3/27/2015 Back to basics : Laryngectomy Preoperative Assessment : Laryngectomy – Diagnosis: cancer, intractable aspiration – Airway assessment/ evaluation…awake trach? – Anticipate DIFFICULT INTUBATION! – Smoke, S k ETOH, ETOH COPD COPD, C Cardiac, di etc. t – Large IV – May turn OR table – Anode tube Intraop/ Emergence: Laryngectomy – Smooth emergence – Mod dec BP – May be combined with neck dissection and PEG placement Maxillofacial Reconstruction –Correct effects of trauma i.e. Leforte Fractures –Congenital malformations –Radical Cancer Surgerymandibulectomy Preoperative Considerations: Maxillofacial Reconstruction Intraoperative: Maxillofacial Reconstruction • Airway evaluation – mouth opening, neck mobility, nasal patency • Blood loss? IVs • Oropharyngeal pack decrease blood going into larynx/trachea • Sharing of space with surgical team – Can you mask ventilate – Awake fiberoptic? Nasal, oral? – Nasal RAE tube, regular tube with connector – Tracheostomy • No nasal intubation with Lefort II and III may have coexisting basilar skull fracture – vigilance with monitoring of tube, ETCO2, esophageal probe?, increased PIP, disconnect of circuit • Extubate @ end – Is there edema, will airway be obstructed? Pt fully awake? • If jaw wired shut be sure to have cutting tools at bedside 7 3/27/2015 Nasal Surgery Procedures • Rhinoplasty • Septoplasty • External or Endoscopic Sinus Surgery General Considerations: Nasal Surgery • Anesthetic Considerations – Local vs. General septoplasty and septorhinoplasty may be performed under local with sedation – IV access – Positioning head elevated 30° 30 ↓ bleeding, bleeding table turned, eye protection – Vasoconstrictors shrink nasal mucosa – Epinephrine 3-5 mcg/kg – Local Anesthetic blocks anterior ethmoidal and sphenopalatine nerves – Cocaine 3mg/kg 30 min max effect Anesthetic Considerations : Nasal Surgery –Throat pack –blood loss/epistaxis (hypotensive technique) –antiemetic antiemetic prophylaxis –emergence/extubation Preoperative Considerations for Nasal Surgery – Nasal Obstruction? (polyps, deviated septum, mucosal congestion) – Hx of bleeding problems Cocaine Cardiovascular effects – Local anesthetic – Reactions not like other local anesthetics – Inhibits reuptake of norepi at adrenergic nerve terminals so potentiates adrenergic responsevasoconstriction of arteries h hypertension and d ventricular l dysrhythmiasmyocardial ischemia – Dysrhythmias treated with Ca+ channel blocker, myocardial ischemia tx with NTG Laser (Light Amplification by Stimulated Emission of Radiation) Surgery – Precision, hemostasis – Minimal edema, pain – Uses and side effects vary with wavelength – CO2 gas long wavelength longer wavelength greater absorption by water, less tissue penetrated (superficial) – YAG shorter wavelength 8 3/27/2015 Perioperative Considerations : Laser –Evacuation of fumes –Protective eye gear for all personnel –Pt. eyes protected –ETT ETT fi fire –Trained Laser operator Prevention of Airway Fire – Metal tube, reinforced tube, metallic tape wrapped around ETT – Keep inspired FiO2 low – No Nitrous Oxide supports combustion – May M fill cuff ff with ith saline li or methylene th l blue bl – Limit laser duration and intensity – Saline soaked pledgets in airway – Source of water immediately available Robotic H&N procedures Treatment of Fires in the OR – **Halt procedure – **Call for help – Airway fire • • • • • IMMEDIATELY, without waiting Remove tracheal tube Stop the flow of all airway gases Remove sponges and flammable material from airway Pour saline l into airway – Non-airway fire • • • • IMMEDIATELY, without waiting Stop the flow of all airway gases Remove drapes and all burning and flammable materials Extinguish burning materials by pouring saline – Reestablish or continue ventilation – Examine airway for damage • Robotic Tonsillectomy • Laser for airway tumors…and cryo, and stenting…plus a little jjet ventilation • Redo surgery after previous thyroidectomy, or radiation, or laryngectomy If Fire is Not Extinguished Use a CO2 fire extinguisher If FIRE PERSISTS: •activate fire alarm •evacuate patient •close OR door •turn off gas supply to room ASA 2013 – Practice Advisory References • Barash et. al. (2013) Clinical Anesthesia (7th ed) Lippincott, Williams & Wilkins • Butterworth, J, Mackey, D & Wasnick, J. (2013) Morgan & Mikhail’s Clinical Anesthesiology ( 5th ed) McGraw Hill • Fleisher, L & Roizen, M (2011) Essence of Anesthesia Practice (3rd ed) Philadelphia: Elsevier • Joseph, A & D’Souza, G. (2012) Epidemiology of Human PapillomavirusRelated Head and Neck Cancer . Otolaryngologic Clinics of North America 45 ( ) 739–764 (4) 6 • Miller, R & Pardo , M. ( 2011) Basics of Anesthesia (6th ed) . Philadelphia: Elsevier • Nagelhout, J. & Plaus, K. (2009) Nurse Anesthesia , (5th ed)St Louis, Missouri: Elsevier • Wyss, A. (2013) Cigarette, Cigar, and Pipe Smoking and the Risk of Head and Neck Cancers: Pooled Analysis in the International Head and Neck Cancer Epidemiology Consortium . American Journal of Epidemiology 178 (5) 679-690 9 3/27/2015 Anesthesia for Head and Neck Cancer Laura L. Ardizzone DNP, CRNA, DCC Director Nurse Anesthesia Services, MSKCC Adjunct Assistant Professor of Nursing Fairfield University School of Nursing [email protected]/www.mskcc.org 10
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